Considering getting out of EM

[DrSkippityPaps]

Wanted to pick some brains.

I'm a PGY-11 and am burnt to a crisp by EM for all the reasons. I'm a DO and while I learned OMM in school, I've never practiced it in residency or in my attendinghood. How does one go about practicing OMM and working in private practice? Anyone with any experience doing this? And what kind of income would be reasonable working 4 days a week? I've paid all my student loans off so can afford to take a pay cut but still want to be able to max out on contributions on my SEP IRA and such.

Any advice would be amazing or if you want to share your side gigs, options of getting out of the ER, etc... I'm all ears.

Stay safe out there.

DrSkippityPaps

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[choks]

I've always thought about opening a cash only OMM clinic. Hope it goes well for you! I know such clinics do exist.

 

[The kitchen sink]

Wanted to pick some brains.

I'm a PGY-11 and am burnt to a crisp by EM for all the reasons. I'm a DO and while I learned OMM in school, I've never practiced it in residency or in my attendinghood. How does one go about practicing OMM and working in private practice? Anyone with any experience doing this? And what kind of income would be reasonable working 4 days a week? I've paid all my student loans off so can afford to take a pay cut but still want to be able to max out on contributions on my SEP IRA and such.

Any advice would be amazing or if you want to share your side gigs, options of getting out of the ER, etc... I'm all ears.

Stay safe out there.

DrSkippityPaps

Did you throw away your green book by Savarese? Lol jk

Start by enrolling in local CME courses

 

[watermanMD]

I thought the evidence base for OMM was about the same as chiropractic…?

 

[Rekt]

I thought the evidence base for OMM was about the same as chiropractic…?

There’s some evidence for low back pain maneuvers but that’s about it.

The rest is imaginary.

But people are dumb and will pay for anything, I.e. see chiropracty

 

[FlaminHotER]

Do weight loss, overall healthy, testosterone, concierge medicine, etc.

You have the training and knowledge

 

[choks]

OMM + Med spa clinic dispensing ozempic to housewives trying to lose weight, IVs for hangovers, concierge premium/minimum spend.

 

[VA Hopeful Dr]

Do weight loss, overall healthy, testosterone, concierge medicine, etc.

You have the training and knowledge

Do you?

 

[FlaminHotER]

Do you?

Yes. It is my side hustle and exit strategy from EM.

If we can take care of poly traumas, septic shock, respiratory failure, septic kids, anaphylactic reactions, and the critically ill…it’s not that freakin hard to figure how to dose ozempic and testosterone! For the love of God

 

[BoardingDoc]

Yes. It is my side hustle and exit strategy from EM.

If we can take care of poly traumas, septic shock, respiratory failure, septic kids, anaphylactic reactions, and the critically ill…it’s not that freakin hard to figure how to dose ozempic and testosterone! For the love of God

My guess is that VA was more asking about your qualifications to do concierge primary care which id argue we do not have training in despite the amount of BS primary care stuff that we routinely see in the ED.

The testosterone and ozempic stuff I would agree is something that requires little more than some thorough reading on top of our existing knowledge.

 

[emergentmd]

I bet it is easier for an EM doc to do primary care than a FM doc work in a rural ER. Even as an shock trauma/top 3 busiest ER trained EM, going to a rural place worries me. Give me a community/crash ER any day with all the support and another EM doc by my side over being by myself any day.

If I were to do PCP, which I would never, what do I need to learn? I already know the UC stuff.

1. Learn the immunization schedule - easy
2. Learn to manage DM, hypertension, etc. If not confortable, refer to specialist. If something acute, send to ER like other PCPs
3. Learn lab order schedule.

Now crucify me. I would not be great, but most pts just care that you listen and nice which I do naturally. I can not tell you how many times I have been asked if I have an outpt office b/c I actually listen/explain what is going on.

 

[The Knife & Gun Club]

I bet it is easier for an EM doc to do primary care than a FM doc work in a rural ER. Even as an shock trauma/top 3 busiest ER trained EM, going to a rural place worries me. Give me a community/crash ER any day with all the support and another EM doc by my side over being by myself any day.

If I were to do PCP, which I would never, what do I need to learn? I already know the UC stuff.

1. Learn the immunization schedule - easy
2. Learn to manage DM, hypertension, etc. If not confortable, refer to specialist. If something acute, send to ER like other PCPs
3. Learn lab order schedule.

Now crucify me. I would not be great, but most pts just care that you listen and nice which I do naturally. I can not tell you how many times I have been asked if I have an outpt office b/c I actually listen/explain what is going on.

I tried to do this at a moonlighting gig and it was much harder than I expected. There’s a lot more nuance to outpatient medicine than we learn in EM. First line HTN/DM management sure. Start statins and give vaccines.

But what about someone who has HTN/HLD/DM and is now having symptoms of worsening renal function? Which meds go down? Which go up? When do they need to see Nephro?

The patient with well controlled HIV who’s now having weird unexplained symptoms? Is it his HIV meds? What are the side effects of these HIV meds? Are they renally cleared or hepatic cleared? He’s got HCV but not cirrhosis. Can he get treated? Will those meds interact?

I had one case of a guy I diagnosed with new onset CHF without exacerbation in a dude with a host of other well controlled medical problems. Awesome let’s start some GDMT. I was a bit too aggressive with my dosing it turns out, he syncopated and hit his head and ended up in the ED (thank god he didn’t have a bleed, he was already on elequis for afib).

Real FM requires real FM training IMO. Sure you could just be like Jenny McJennerson NP PA DM OSA HTN, roulette wheel choosing and dosing meds and hope you’re right because usually it will be fine. But do you want that? As silly as it sounds we took an oath. First do no harm, or more simply put First don’t suck at your job.

 

[Brigade4Radiant]

I tried to do this at a moonlighting gig and it was much harder than I expected. There’s a lot more nuance to outpatient medicine than we learn in EM. First line HTN/DM management sure. Start statins and give vaccines.

But what about someone who has HTN/HLD/DM and is now having symptoms of worsening renal function? Which meds go down? Which go up? When do they need to see Nephro?

The patient with well controlled HIV who’s now having weird unexplained symptoms? Is it his HIV meds? What are the side effects of these HIV meds? Are they renally cleared or hepatic cleared? He’s got HCV but not cirrhosis. Can he get treated? Will those meds interact?

I had one case of a guy I diagnosed with new onset CHF without exacerbation in a dude with a host of other well controlled medical problems. Awesome let’s start some GDMT. I was a bit too aggressive with my dosing it turns out, he syncopated and hit his head and ended up in the ED (thank god he didn’t have a bleed, he was already on elequis for afib).

Real FM requires real FM training IMO. Sure you could just be like Jenny McJennerson NP PA DM OSA HTN, roulette wheel choosing and dosing meds and hope you’re right because usually it will be fine. But do you want that? As silly as it sounds we took an oath. First do no harm, or more simply put First don’t suck at your job.

Refer like when they send it to the ED and honesltly a lot of that needs an Internist not a FM. FM is pretty broad and they see kids but they are not pediatricians and OB and deliver babies as well.

 

[hopefulgasman]

I tried to do this at a moonlighting gig and it was much harder than I expected. There’s a lot more nuance to outpatient medicine than we learn in EM. First line HTN/DM management sure. Start statins and give vaccines.

But what about someone who has HTN/HLD/DM and is now having symptoms of worsening renal function? Which meds go down? Which go up? When do they need to see Nephro?

The patient with well controlled HIV who’s now having weird unexplained symptoms? Is it his HIV meds? What are the side effects of these HIV meds? Are they renally cleared or hepatic cleared? He’s got HCV but not cirrhosis. Can he get treated? Will those meds interact?

I had one case of a guy I diagnosed with new onset CHF without exacerbation in a dude with a host of other well controlled medical problems. Awesome let’s start some GDMT. I was a bit too aggressive with my dosing it turns out, he syncopated and hit his head and ended up in the ED (thank god he didn’t have a bleed, he was already on elequis for afib).

Real FM requires real FM training IMO. Sure you could just be like Jenny McJennerson NP PA DM OSA HTN, roulette wheel choosing and dosing meds and hope you’re right because usually it will be fine. But do you want that? As silly as it sounds we took an oath. First do no harm, or more simply put First don’t suck at your job.

Some of what you’re describing should be managed by a specialist, not by FM….sure some do in extremely rural places where there’s only one X for another X miles. Otherwise, don’t overextend yourself. Knowing your limits is part of doing no harm.

 

[EMhawkeye]

Some of what you’re describing should be managed by a specialist, not by FM….sure some do in extremely rural places where there’s only one X for another X miles. Otherwise, don’t overextend yourself. Knowing your limits is part of doing no harm.

Sounds like you work with a lot of pcp’s who turn their brains off and refer everything.

 

[Brigade4Radiant]

Sounds like you work with a lot of pcp’s who turn their brains off and refer everything.

Which is the standard I don't see how you can adequately see all these types of complex adult problems with a FM residency which is broad enough and deal with kids, ob and ortho stuff.

I mean if we are going to use the excuse that EM doctor with a decade of experience and CME who sees all walks of life isn't trained to do any longitudinal clinical work then how can FM say they can do specialist clinic work to the standard of a specialist?

 

[EMhawkeye]

Which is the standard I don't see how you can adequately see all these types of complex adult problems with a FM residency which is broad enough and deal with kids, ob and ortho stuff.

I mean if we are going to use the excuse that EM doctor with a decade of experience and CME who sees all walks of life isn't trained to do any longitudinal clinical work then how can FM say they can do specialist clinic work to the standard of a specialist?

Which condition there would you refer to a specialist?
Dm/ htn/ hld/ hiv, all within the purview of primary care.
If you refer everything to specialists, you aren’t a primary care physician, you’re a guy with a rx pad who knows a lot of doctors.
Not sure if you have seen the depth of a good family medicine residency training.

 

[Brigade4Radiant]

Which condition there would you refer to a specialist?
Dm/ htn/ hld/ hiv, all within the purview of primary care.
If you refer everything to specialists, you aren’t a primary care physician, you’re a guy with a rx pad who knows a lot of doctors.
Not sure if you have seen the depth of a good family medicine residency training.

Primary care is very vast also dm/htn/hiv are not new things for a EM doc to treat and all of these have specialists. Also are you arguing that your care is as good as a lipidologist for hln?

Also the good FM training is not standardized FM is highly variable

 

[EMhawkeye]

Primary care is very vast also dm/htn/hiv are not new things for a EM doc to treat and all of these have specialists. Also are you arguing that your care is as good as a lipidologist for hln?

Also the good FM training is not standardized FM is highly variable

The idea of a “lipidologist” managing hld is as ridiculous as an orthopod who only does right sided hip replacement. If a family medicine physician practicing primary care doesn’t know lipid management like the back of their hand needs to hang up their stethoscope.
That’s as crazy as saying an em attending needs to do a geriatric em fellowship to treat people over 65.

 

[RustedFox]

Now crucify me. I would not be great, but most pts just care that you listen and nice which I do naturally. I can not tell you how many times I have been asked if I have an outpt office b/c I actually listen/explain what is going on.

I woke up and chose "Paladin" today.
Crucifixions are right up my alley.
Prepare to be smited, heretic.
God's will shall be done by my hand.
NONE SHALL ESCAPE JUDGMENT!

s/hitposting.

 

[Brigade4Radiant]

The idea of a “lipidologist” managing hld is as ridiculous as an orthopod who only does right sided hip replacement. If a family medicine physician practicing primary care doesn’t know lipid management like the back of their hand needs to hang up their stethoscope.
That’s as crazy as saying an em attending needs to do a geriatric em fellowship to treat people over 65.

But they do exist I mean why would their be a fellowship for cards if they weren't needed? I also know orthos who don't do hands or spine. Or doing a Peds EM fellowship to see kids. If the standard is to be the best.

 

[greatnt249]

Primary care is very vast also dm/htn/hiv are not new things for a EM doc to treat and all of these have specialists. Also are you arguing that your care is as good as a lipidologist for hln?

Also the good FM training is not standardized FM is highly variable

If you can't treat HTN, diabetes, and dyslipidemia for the grand majority of the patients that come through your office without referring out to a specialist, you have no business being an outpatient internist/family medicine doctor. At that point, I question what exactly it is that you're capable of managing independently.

 

[Brigade4Radiant]

If you can't treat HTN, diabetes, and dyslipidemia for the grand majority of the patients that come through your office without referring out to a specialist, you have no business being an outpatient internist/family medicine doctor. At that point, I question what exactly it is that you're capable of managing independently.

But no one is saying about HTN, DM or HLD I’m talking about all the complicated scenarios that get brought up when a EM doc wants to do basic clinic stuff

 

[voxveritatisetlucis]

Wouldn’t this be essentially selling snake oil since there are no peer reviewed studies demonstrating the efficacy of OMM

 

[RustedFox]

Wouldn’t this be essentially selling snake oil since there are no peer reviewed studies demonstrating the efficacy of OMM

Shhh. You said the quiet part out loud.

 

[EMhawkeye]

But no one is saying about HTN, DM or HLD I’m talking about all the complicated scenarios that get brought up when a EM doc wants to do basic clinic stuff

So what are asking?
What is taught in an fm residency regarding primary care of medically complex patients that em docs aren’t taught? A lot.
Not all medically complex patients require subspecialty referral. And when they do, they still need a medical home and pcp overseeing it.
Do you know preventive screening guidelines verbatim?
How many patients have you titrated statins/ acei’s/ allopurinol on?

 

[VA Hopeful Dr]

Well, this certainly took off in a delightfully predictable direction.

Y'all are taking the same mindset of primary care that the hospitalists often do towards you. They get mad about admissions forgetting the 20 patients you saw and discharged without them knowing it. You see the stuff we send to you (and not even all of us), and forget the 60 other patients we've seen that week that didn't get sent to you.

The only reason to refer to a "lipid specialist" if you're FM trained is a) patient's insurance won't cover a PSK-9 unless written by a cardiologist or lipid specialist (though I will lie and say I have consulted with the latter) or b) the patient demands it and you can't talk them out of it since we all know satisfaction trumps good care these days.

No, not all fellowships are needed or even necessary. Peds hospitalist springs to mind most readily. Just because a fellowship exists doesn't mean its worthwhile.

Just because you can manage sepsis and I can't doesn't make my job intellectually easier than yours nor does it mean you can easily do my job. Good primary care without being a referral machine isn't easy. Sometimes it is, just like some ED patients require little thought/effort on your part to deal with. Often times is isn't. Uncontrolled HTN with CKD, uncontrolled DM with known retinopathy, and sky high triglycerides and oh by the way having a gout flare. That sort of thing isn't all that unusual for me. 2 of the most popular DM meds are contraindicated with retinopathy with another running the risk of worsening CKD and another dependent on the exact GFR to know if its safe while a 4th is known to cause hypoglycemia with CKD. 2 of the 3 acute gout meds are contraindicated by CKD and uncontrolled DM. 1 of our first line BP meds is contraindicated with uncontrolled gout while another can worsen CKD and a 3rd can worsen lipid levels and if that triglyceride level is high enough combined with bad enough DM you run the risk of pancreatitis which oh by the way is a known side effect of yet another class of DM meds. But if its just the triglycerides it could be caused by the hyperglycemia so do you treat now or wait and see what it does when the sugar level gets better? So you have to decide what to do about all of these, how soon to follow up, things the patient needs to monitor and what to do if X, Y, or Z happens symptom wise, what testing to order and when. Oh, and you have 15 minutes to do all of that and an exam and listen to their story about the time they had gout back in '73 because they tied an onion on their belt which was the style at the time.

I'm not at all saying you aren't capable of that sort of thing because there are plenty of problems y'all see in the ED that require just as many thoughts going on at the same time with other patients waiting some of whom are critically ill. But you're trained for ED problems and the ED work flow while I'm trained to do my scenario with the resources and time-constraints dictated by outpatient practice (for example, stat labs aren't a thing - its 12 hours minimum for any non-POC testing).

As I've said before, we're all physicians first. We did the same 4 years of medical training. So you in all likelihood could do CME and reading and with time get to be pretty good at outpatient primary care. But I would truly appreciate it if you didn't pretend that a 4 hour CME course and some light reading would make you my equal in primary care. It would not.

 

[EMhawkeye]

Well, this certainly took off in a delightfully predictable direction.

Y'all are taking the same mindset of primary care that the hospitalists often do towards you. They get mad about admissions forgetting the 20 patients you saw and discharged without them knowing it. You see the stuff we send to you (and not even all of us), and forget the 60 other patients we've seen that week that didn't get sent to you.

The only reason to refer to a "lipid specialist" if you're FM trained is a) patient's insurance won't cover a PSK-9 unless written by a cardiologist or lipid specialist (though I will lie and say I have consulted with the latter) or b) the patient demands it and you can't talk them out of it since we all know satisfaction trumps good care these days.

No, not all fellowships are needed or even necessary. Peds hospitalist springs to mind most readily. Just because a fellowship exists doesn't mean its worthwhile.

Just because you can manage sepsis and I can't doesn't make my job intellectually easier than yours nor does it mean you can easily do my job. Good primary care without being a referral machine isn't easy. Sometimes it is, just like some ED patients require little thought/effort on your part to deal with. Often times is isn't. Uncontrolled HTN with CKD, uncontrolled DM with known retinopathy, and sky high triglycerides and oh by the way having a gout flare. That sort of thing isn't all that unusual for me. 2 of the most popular DM meds are contraindicated with retinopathy with another running the risk of worsening CKD and another dependent on the exact GFR to know if its safe while a 4th is known to cause hypoglycemia with CKD. 2 of the 3 acute gout meds are contraindicated by CKD and uncontrolled DM. 1 of our first line BP meds is contraindicated with uncontrolled gout while another can worsen CKD and a 3rd can worsen lipid levels and if that triglyceride level is high enough combined with bad enough DM you run the risk of pancreatitis which oh by the way is a known side effect of yet another class of DM meds. But if its just the triglycerides it could be caused by the hyperglycemia so do you treat now or wait and see what it does when the sugar level gets better? So you have to decide what to do about all of these, how soon to follow up, things the patient needs to monitor and what to do if X, Y, or Z happens symptom wise, what testing to order and when. Oh, and you have 15 minutes to do all of that and an exam and listen to their story about the time they had gout back in '73 because they tied an onion on their belt which was the style at the time.

I'm not at all saying you aren't capable of that sort of thing because there are plenty of problems y'all see in the ED that require just as many thoughts going on at the same time with other patients waiting some of whom are critically ill. But you're trained for ED problems and the ED work flow while I'm trained to do my scenario with the resources and time-constraints dictated by outpatient practice (for example, stat labs aren't a thing - its 12 hours minimum for any non-POC testing).

As I've said before, we're all physicians first. We did the same 4 years of medical training. So you in all likelihood could do CME and reading and with time get to be pretty good at outpatient primary care. But I would truly appreciate it if you didn't pretend that a 4 hour CME course and some light reading would make you my equal in primary care. It would not.

👏

 

[The Knife & Gun Club]

Well, this certainly took off in a delightfully predictable direction.

Y'all are taking the same mindset of primary care that the hospitalists often do towards you. They get mad about admissions forgetting the 20 patients you saw and discharged without them knowing it. You see the stuff we send to you (and not even all of us), and forget the 60 other patients we've seen that week that didn't get sent to you.

The only reason to refer to a "lipid specialist" if you're FM trained is a) patient's insurance won't cover a PSK-9 unless written by a cardiologist or lipid specialist (though I will lie and say I have consulted with the latter) or b) the patient demands it and you can't talk them out of it since we all know satisfaction trumps good care these days.

No, not all fellowships are needed or even necessary. Peds hospitalist springs to mind most readily. Just because a fellowship exists doesn't mean its worthwhile.

Just because you can manage sepsis and I can't doesn't make my job intellectually easier than yours nor does it mean you can easily do my job. Good primary care without being a referral machine isn't easy. Sometimes it is, just like some ED patients require little thought/effort on your part to deal with. Often times is isn't. Uncontrolled HTN with CKD, uncontrolled DM with known retinopathy, and sky high triglycerides and oh by the way having a gout flare. That sort of thing isn't all that unusual for me. 2 of the most popular DM meds are contraindicated with retinopathy with another running the risk of worsening CKD and another dependent on the exact GFR to know if its safe while a 4th is known to cause hypoglycemia with CKD. 2 of the 3 acute gout meds are contraindicated by CKD and uncontrolled DM. 1 of our first line BP meds is contraindicated with uncontrolled gout while another can worsen CKD and a 3rd can worsen lipid levels and if that triglyceride level is high enough combined with bad enough DM you run the risk of pancreatitis which oh by the way is a known side effect of yet another class of DM meds. But if its just the triglycerides it could be caused by the hyperglycemia so do you treat now or wait and see what it does when the sugar level gets better? So you have to decide what to do about all of these, how soon to follow up, things the patient needs to monitor and what to do if X, Y, or Z happens symptom wise, what testing to order and when. Oh, and you have 15 minutes to do all of that and an exam and listen to their story about the time they had gout back in '73 because they tied an onion on their belt which was the style at the time.

I'm not at all saying you aren't capable of that sort of thing because there are plenty of problems y'all see in the ED that require just as many thoughts going on at the same time with other patients waiting some of whom are critically ill. But you're trained for ED problems and the ED work flow while I'm trained to do my scenario with the resources and time-constraints dictated by outpatient practice (for example, stat labs aren't a thing - its 12 hours minimum for any non-POC testing).

As I've said before, we're all physicians first. We did the same 4 years of medical training. So you in all likelihood could do CME and reading and with time get to be pretty good at outpatient primary care. But I would truly appreciate it if you didn't pretend that a 4 hour CME course and some light reading would make you my equal in primary care. It would not.

Exactly. As a doc we all certainly could learn a new speciality with enough time and resources. But that doesn’t mean you should be practicing without that training.

Right now in my fellowship and all of my co-fellows are all surgeons. It definitely took me a hot minute to get up to speed but everything is totally learnable. It took 6 months to just a get a basic level of comfort with a new patient population and disease panel though.

Every specialty has their own considerations and while a lot of them overlap with EM there’s still a substantial body of knowledge that needs to be learned with dedicated study and supervised practice to do it well.

 

[Birdstrike]

If you feel God put you here to practice Emergency Medicine, then do it and bear the burden proudly. If you don't, then waste not another minute hesitating to do what God did put you here to do.

 

[RustedFox]

If you feel God put you here to practice Emergency Medicine, then do it and bear the burden proudly. If you don't, then waste not another minute hesitating to do what God did put you here to do.

I struggled with this for long.
You (I) can indeed... be wrong.
What we thought EM would be, is not what it was - and certainly not what it used to be.

 

[Siggy]

Refer like when they send it to the ED and honesltly a lot of that needs an Internist not a FM. FM is pretty broad and they see kids but they are not pediatricians and OB and deliver babies as well.

I don't see why FM can't do emergency medicine.

...you know... they likely have a good idea on the urgent care and outpatient stuff. The resuscitation? Levophed through a 22 gauge in the hand ("peripheral pressors") and just admit immediately to the ICU. Let critical care do the resuscitation... after all there's a waiting room full of boo boos to tend to. Vent settings? 500ml TV, rate of 16, 100% FiO2, and a PEEP of zero... because the patient's on levo. Also no propofol... only versed because who doesn't love worse outcomes?

 

[Brigade4Radiant]

I don't see why FM can't do emergency medicine.

...you know... they likely have a good idea on the urgent care and outpatient stuff. The resuscitation? Levophed through a 22 gauge in the hand ("peripheral pressors") and just admit immediately to the ICU. Let critical care do the resuscitation... after all there's a waiting room full of boo boos to tend to. Vent settings? 500ml TV, rate of 16, 100% FiO2, and a PEEP of zero... because the patient's on levo. Also no propofol... only versed because who doesn't love worse outcomes?

FM does EM in Canada and various places I don’t see why it isn’t a fellowship of EM

 

[VA Hopeful Dr]

FM does EM in Canada and various places I don’t see why it isn’t a fellowship of EM

Mainly because there aren't real fellowships (ABMS) that train anyone to practice in another specialty that has its own separate residency pathway already set up.

But there also hasn't been any demand for this until pretty recently. 10 years ago EM was still super competitive and I don't remember hearing much discontent about the specialty overall.

In terms of logistics, to do it right it would need to be a 2 year program. Picking up the new information wouldn't take that long, but if you're going to learn to manage chronic diseases you need to follow patients for more than 1 year.

 

[GatorCHOMPions]

FM does EM in Canada and various places I don’t see why it isn’t a fellowship of EM

There are already EM-FM combined programs which are 5 years long. Perhaps this is one angle to approach the issue for anyone interested to start a pathway for an “add-on” FM residency after finishing an EM residency.

 

[Siggy]

FM does EM in Canada and various places I don’t see why it isn’t a fellowship of EM

Sure... 2 year fellowship and you can be a PCP.

However in this thread people aren't even talking about formal training. It's 10 years of EM and a few CME videos... and suddenly the EM doc is the same as a residency trained IM or FM doc.

...meanwhile 10 years ago on here it was, "EM is the master of the undifferentiated patient and resuscitation" and now it's, "We don't have time to resuscitate or properly work up patients, so we'll just admit them and let other teams do our jobs."

...and if you think I'm wrong... please explain why last week I was consulted for a postpartum preeclampsia patient without a UA (no proteinuremia when we got it back) and on a cardene GTT instead of a mag GTT. 2 Months ago it was the emergency department trying to pawn off a facial burn/possible airway burn patient (patient tried lighting a candle while on BiPAP) without even talking to the burn center (burn center immediately accepted the patient).

So the thoughts of modern EPs going, "With 10 years experience and a few CMEs we can do FM's or IM's jobs... but you have to do an EM residency to be a proper emergency physician" is... interesting.

 

[BoardingDoc]

...and if you think I'm wrong... please explain why last week I was consulted for a postpartum preeclampsia patient without a UA (no proteinuremia when we got it back) and on a cardene GTT instead of a mag GTT. 2 Months ago it was the emergency department trying to pawn off a facial burn/possible airway burn patient (patient tried lighting a candle while on BiPAP) without even talking to the burn center (burn center immediately accepted the patient).

1: I'm also in the camp that EM requires more than CME and reading to be a PCP.

2: don't assume that all EPs are pawning off their patients without doing an appropriate workup simply because of your aforementioned anecdotes. I don't assume all hospitalists are idiots simply because one of mine asked me yesterday to phenobarb load a barely conscious patient who I had just narcaned for a RR of 4. I politely declined to kill the patient. Or the one who last month refused to admit a lady with an nstemi and a fall because the trop bump "was probably just from her hitting her chest anyway and she can go home." Cool, so it's not an MI, it's a cardiac contusion causing a trop leak...that you want me to DC. Brilliant. No. All of that said, I don't think it behooves anyone for me to conflate the intelligence of all hospitalists with that of their lowest common denominator.

 

[Groove]

I've often said that I wish EM had an outpatient medicine "OM" fellowship that was 2 years in length and prepared us to do preventative/outpatient medicine in a clinic setting. That would be such a glorious way out for many of us. I guess the closest we have are the EM/FM combined residencies. We had a resident kicked out of residency during his first year and faculty helped him get a spot in a nearby FM/EM program. I remember thinking how much that sucked to have his residency extended for a year. Talk about divine providence. That was probably the best thing that ever happened to him.

 

[dozitgetchahi]

Sure... 2 year fellowship and you can be a PCP.

However in this thread people aren't even talking about formal training. It's 10 years of EM and a few CME videos... and suddenly the EM doc is the same as a residency trained IM or FM doc.

...meanwhile 10 years ago on here it was, "EM is the master of the undifferentiated patient and resuscitation" and now it's, "We don't have time to resuscitate or properly work up patients, so we'll just admit them and let other teams do our jobs."

...and if you think I'm wrong... please explain why last week I was consulted for a postpartum preeclampsia patient without a UA (no proteinuremia when we got it back) and on a cardene GTT instead of a mag GTT. 2 Months ago it was the emergency department trying to pawn off a facial burn/possible airway burn patient (patient tried lighting a candle while on BiPAP) without even talking to the burn center (burn center immediately accepted the patient).

So the thoughts of modern EPs going, "With 10 years experience and a few CMEs we can do FM's or IM's jobs... but you have to do an EM residency to be a proper emergency physician" is... interesting.

Yup. Agree completely.

 

[Rekt]

Sure... 2 year fellowship and you can be a PCP.

However in this thread people aren't even talking about formal training. It's 10 years of EM and a few CME videos... and suddenly the EM doc is the same as a residency trained IM or FM doc.

...meanwhile 10 years ago on here it was, "EM is the master of the undifferentiated patient and resuscitation" and now it's, "We don't have time to resuscitate or properly work up patients, so we'll just admit them and let other teams do our jobs."

...and if you think I'm wrong... please explain why last week I was consulted for a postpartum preeclampsia patient without a UA (no proteinuremia when we got it back) and on a cardene GTT instead of a mag GTT. 2 Months ago it was the emergency department trying to pawn off a facial burn/possible airway burn patient (patient tried lighting a candle while on BiPAP) without even talking to the burn center (burn center immediately accepted the patient).

So the thoughts of modern EPs going, "With 10 years experience and a few CMEs we can do FM's or IM's jobs... but you have to do an EM residency to be a proper emergency physician" is... interesting.

Aren't you IM? Why are they even talking to you.

Also, protein in the urine is not an used/required for a diagnosis of pre-eclampsia anymore. And, Mg isn't for hypertension/hypertensive emergency in pregnancy, it's for seizure prophylaxis. Labetalol and then CCBs are standard of care and first and second line. Strict BP control is at least as important or more important than Mg initially anyway. And no EM OR IM doc on earth is doing a 4-6g Mg + drip without at least talking with Ob. These typically go to the ICU anyway. And prophylactic intubation for facial burns almost never happens anymore. He likely went to the burn center and they did nothing for 24hrs and discharged him.

That's all beside the point anyway. This thread is a perfect example of the real problem with medicine, pointless physician infighting, when the real problem is the monkey suits upstairs working banker hours doing nothing for six figures.

 

[Siggy]

Aren't you IM? Why are they even talking to you.

Also, protein in the urine is not an used/required for a diagnosis of pre-eclampsia anymore. And, Mg isn't for hypertension/hypertensive emergency in pregnancy, it's for seizure prophylaxis. Labetalol and then CCBs are standard of care and first and second line. Strict BP control is at least as important or more important than Mg initially anyway. And no EM OR IM doc on earth is doing a 4-6g Mg + drip without at least talking with Ob. These typically go to the ICU anyway. And prophylactic intubation for facial burns almost never happens anymore. He likely went to the burn center and they did nothing for 24hrs and discharged him.

That's all beside the point anyway. This thread is a perfect example of the real problem with medicine, pointless physician infighting, when the real problem is the monkey suits upstairs working banker hours doing nothing for six figures.

I'm IM-Critical Care. I guess those patients could have been admited to tele instead. Then, yes, they don't need to talk with me. However don't admit a patient to a hospital that lacks the resources (e.g. the burn patient in this case, my hosptial has L&D) and then expect me to do an inpatient to inpatient transfer for you.

The preeclamptic patient still needs mag. For proteinuria, are you making an argument that any new onset HTN in the first 6 weeks post partum is automatically preeclampsia regardless of the presence or lack of other findings? Unfortunately I don't have access to AJOG/ACOG, so I can't access their guidelines. IBCC still lists it (Preeclampsia & HELLP). ...oh, and the EM physician did talk with OB, who was recommending mag.

I never said that the burn patient needed to be intubated, but I said he needed to be referred to a burn center. If the burn center took a pass on the patient, then sure... admit. However how can you justify not even giving the burn center a call with 2 separate criteria for "Immediate Consultation with Consideration for Transfer" (https://ameriburn.org/wp-content/up...e-guidelines-for-burn-patient-referral-16.pdf)? Put another way, knowing what the standard of care is, would you be willing to admit that patient to yourself?

 

[Cinclus]

If you feel God put you here to practice Emergency Medicine, then do it and bear the burden proudly. If you don't, then waste not another minute hesitating to do what God did put you here to do.

Hike to very remote places and take nice pictures of the scenery? THE LORD HAS CALLED ME AWAY FROM THE ED.

I have already cut back on my hours quite a bit in the past year. It has been great. Not sure I'm ready to completely hang it up yet. Seems like a waste, since I'm pretty young and seemingly competent at my job. I have a lot of other things I could be throwing myself into, though. I'm almost five years out of residency. Will I make it to ten? Dunno. I'll likely never do full-time EM ever again. It's very questionable whether I should have even done medicine. I think I sort of did it because I could and didn't have a better idea at the time. Oh, man, if I had answered those med school interviewers honestly, lol.

 

[The Knife & Gun Club]

I'm IM-Critical Care. I guess those patients could have been admited to tele instead. Then, yes, they don't need to talk with me. However don't admit a patient to a hospital that lacks the resources (e.g. the burn patient in this case, my hosptial has L&D) and then expect me to do an inpatient to inpatient transfer for you.

The preeclamptic patient still needs mag. For proteinuria, are you making an argument that any new onset HTN in the first 6 weeks post partum is automatically preeclampsia regardless of the presence or lack of other findings? Unfortunately I don't have access to AJOG/ACOG, so I can't access their guidelines. IBCC still lists it (Preeclampsia & HELLP). ...oh, and the EM physician did talk with OB, who was recommending mag.

I never said that the burn patient needed to be intubated, but I said he needed to be referred to a burn center. If the burn center took a pass on the patient, then sure... admit. However how can you justify not even giving the burn center a call with 2 separate criteria for "Immediate Consultation with Consideration for Transfer" (https://ameriburn.org/wp-content/up...e-guidelines-for-burn-patient-referral-16.pdf)? Put another way, knowing what the standard of care is, would you be willing to admit that patient to yourself?

Oh the absolute hot garbage I admit to the unit from the ED is mind blowing for sure. As an EP I probably admit at least one per shift where I can look the doc in the eye and say “today you did bad EM”

But it’s not a new doc every time it’s usually the same 1-2 out of a pool of 20-30 attendings.

I’m sure there’s lots of people who could reach that low bar with minimal extra training. But I don’t think it’s anyone’s goal to strive to be that doc that when their name is on the board everyone is sad.

It’s also always easy to Monday morning QB from the intensive care side. How many admits do we do in a shift? Maybe 6 in 12 hours at most? The numbers difference is just insane.

 

[The kitchen sink]

Aren't you IM? Why are they even talking to you.

Also, protein in the urine is not an used/required for a diagnosis of pre-eclampsia anymore. And, Mg isn't for hypertension/hypertensive emergency in pregnancy, it's for seizure prophylaxis. Labetalol and then CCBs are standard of care and first and second line. Strict BP control is at least as important or more important than Mg initially anyway. And no EM OR IM doc on earth is doing a 4-6g Mg + drip without at least talking with Ob. These typically go to the ICU anyway. And prophylactic intubation for facial burns almost never happens anymore. He likely went to the burn center and they did nothing for 24hrs and discharged him.

That's all beside the point anyway. This thread is a perfect example of the real problem with medicine, pointless physician infighting, when the real problem is the monkey suits upstairs working banker hours doing nothing for six figures.

It’s true….They actually literally do nothing…

.Except obstruct care and cut salaries and bonuses or move the goal post further and further away every year so you cannot attain your bonus

 

[Nocturnist]

I bet it is easier for an EM doc to do primary care than a FM doc work in a rural ER. Even as an shock trauma/top 3 busiest ER trained EM, going to a rural place worries me. Give me a community/crash ER any day with all the support and another EM doc by my side over being by myself any day.

If I were to do PCP, which I would never, what do I need to learn? I already know the UC stuff.

1. Learn the immunization schedule - easy
2. Learn to manage DM, hypertension, etc. If not confortable, refer to specialist. If something acute, send to ER like other PCPs
3. Learn lab order schedule.

Now crucify me. I would not be great, but most pts just care that you listen and nice which I do naturally. I can not tell you how many times I have been asked if I have an outpt office b/c I actually listen/explain what is going on.

Jesus Christ dude.

There's some pretty hard data that mortality increases exponentially with ED boarding times.

I love all you EM docs, you're the experts in the first 15 minutes, but ya'll do not have the training to take care of patients beyond the first 4-6 hours.

Ask an ER doc to reconcile a med rec and decide which chronic meds to continue or discontinue, they're lucky if they get them right 50/50.

Now you think you can bypass a 3 year residency? Just because patients are medically illiterate doesn't mean their PCP should be, too.

 

[RustedFox]

Jesus Christ dude.

There's some pretty hard data that mortality increases exponentially with ED boarding times.

I love all you EM docs, you're the experts in the first 15 minutes, but ya'll do not have the training to take care of patients beyond the first 4-6 hours.

Ask an ER doc to reconcile a med rec and decide which chronic meds to continue or discontinue, they're lucky if they get them right 50/50.

Now you think you can bypass a 3 year residency? Just because patients are medically illiterate doesn't mean their PCP should be, too.

We had a "sentinel event" a few weeks back in the ER.
Boarding patient died because... whoops...

Magically, beds upstairs became available !
I'm looking at you, administration.

 

[Siggy]

Oh the absolute hot garbage I admit to the unit from the ED is mind blowing for sure. As an EP I probably admit at least one per shift where I can look the doc in the eye and say “today you did bad EM”

But it’s not a new doc every time it’s usually the same 1-2 out of a pool of 20-30 attendings.

I’m sure there’s lots of people who could reach that low bar with minimal extra training. But I don’t think it’s anyone’s goal to strive to be that doc that when their name is on the board everyone is sad.

It’s also always easy to Monday morning QB from the intensive care side. How many admits do we do in a shift? Maybe 6 in 12 hours at most? The numbers difference is just insane.

It think it depends on what the hot garbage is. Especially if we're low census and it's a, "We/hospitalist wants to watch for 24 hours" then sure.

It's different when it comes to patients that need to be transferred because those takes an insane amount of effort and time to actually move. My last inpatient STEMI, for example, took 6 hours to leave, half of that was because the closest STEMI center (county hospital) straight up refused the transfer.

...and then you have this thread where people are arguing that, despite not stepping foot in a clinic in 10+ years, they can dominate outpatient with some CME videos for no other reason than they can refer what they're uncomfortable with. Like, sure, I get that that's what the PLPs do... but that doesn't mean it should be something to aspire to.

 

[Nocturnist]

We had a "sentinel event" a few weeks back in the ER.
Boarding patient died because... whoops...

Magically, beds upstairs became available !
I'm looking at you, administration.

I've told this story before but it's worth repeating.

Because our boarding times were so long, we piloted the ER writing "bridging orders" just to get the patient upstairs, which included literally just an admit order, a diet order, code status, and dvt ppx.

Bleeders were getting lovenox.
Dysphagia patients were choking on their regular diets.
DNR/DNIs with a valid molst were getting coded.

We scrapped that within a couple months and banned it in the hospital bylaws.

 

[Maybedoc1]

I've often said that I wish EM had an outpatient medicine "OM" fellowship that was 2 years in length and prepared us to do preventative/outpatient medicine in a clinic setting. That would be such a glorious way out for many of us. I guess the closest we have are the EM/FM combined residencies. We had a resident kicked out of residency during his first year and faculty helped him get a spot in a nearby FM/EM program. I remember thinking how much that sucked to have his residency extended for a year. Talk about divine providence. That was probably the best thing that ever happened to him.

I’ve wondered if someone wanted to do a second residency in IM or FM after completing an EM residency would it still be 3 years or would they count an intern year making it two?

 

[Rekt]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people. You can’t preach about how good you are when you hand off an entire icu census to someone who got their degree online.

All of Medicine is a dumpster.